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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609763
Report Date: 09/09/2024
Date Signed: 09/09/2024 03:22:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2024 and conducted by Evaluator Gina Saucedo
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20240228152538
FACILITY NAME:BLUE SKIES RANCHFACILITY NUMBER:
197609763
ADMINISTRATOR:KRAKOVER, EILENEFACILITY TYPE:
740
ADDRESS:6061 SHIRLEY AVETELEPHONE:
(818) 730-4182
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:6CENSUS: 4DATE:
09/09/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Eilene KrakoverTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Staff do not ensure that resident's hygiene needs are met while in care
INVESTIGATION FINDINGS:
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On 09/09/24, at 9:50am, Licensing Program Analyst (LPA) Gina Saucedo and Angelica Segovia arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Administrator, Eilene Krakover. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint.

On 03/05/2024, Licensing Program Analyst (LPA) Tuesday Cabiness initiated the complaint investigation. On 09/09/24, LPA Saucedo and LPA Segovia asked for the census, staff, and resident rosters. On 09/09/24, LPA Saucedo interviewed additional staff and residents, conducted a physical tour, gathered additional information, and delivered findings.

LIC 9099C-continued
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20240228152538
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BLUE SKIES RANCH
FACILITY NUMBER: 197609763
VISIT DATE: 09/09/2024
NARRATIVE
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Regarding the allegation: Staff do not ensure that resident's hygiene needs are met while in care. It is being alleged that the resident’s care is being neglected. Although four (4) out of four (4) residents confirmed that their hygiene needs are met, LPA reviewed the file of resident #1 (R1) who needed assistance with several hygiene needs and was missing documentation. R1's file did not have a Preplacement Appraisal and Resident Appraisal documentation on file. The Appraisal/Needs and Services Plan states R1 needed help with incontinence, bath/shower, eating, and leg elevation. Physician's report stated R1 was ambulatory but R1 was bedridden and had Traumatic Brain Injury. LPA asked the administrator about hospice care and administrator stated they had six (6) waivers. LPA asked another staff if R1 received hospice care or home health and they stated, "no." According to staff interviews, it was confirmed that R1 did need more hygiene care than other residents. Therefore, based on the LPA's records review, staff and resident interviews, the above allegation(s) above is SUBSTANTIATED at this time.

An exit interview was conducted, a citation(s) was issued for the above allegation(s), and a copy of this report was given to the Administrator with the Appeals Right.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20240228152538
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLUE SKIES RANCH
FACILITY NUMBER: 197609763
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2024
Section Cited
CCR
87464(d)
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Basic Services-87464(d)A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources.This requirement was not met as evidenced by:
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Administrator will need to provide the proper hygiene needs to all resident's in care according to their individual needs by trraining all staff.

POC Date: 09/10/24
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Based on the LPA's observation, file review and interviews the administrator did not ensure one out of one file at the facility to have a preappriasal, resident appraisal and correct information on the physician's reportl which poses an Immediate Health, Safety or Personal Rights/risks to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC9099 (FAS) - (06/04)
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